Antidepressant combinations preferred for resistant illness.

Barcelona--Antidepressant combinations should be the preferred treatment option for patients with depression who do not respond to a first-line strategy, according to a new algorithm proposed by the Antidepressant Combinations Working Group of Spain.

'Antidepressant combinations have moved up from being a marginal option or third-step treatment to being the preferred option for treatment-resistant patients," Dr. Jesus de la Gandara, a member of the group, reported in a poster presented at the annual congress of the European College of Neuropsychopharmacology

The algorithm, an update to the 2005 recommendations, includes two fairly recently introduced antidepressants--duloxetine (Cymbalta) and escitalopram (Lexapro)--as well as "a more rational use of antidepressant combinations as the leading choice for the management of treatment-resistant patients or particularly serious cases," wrote Dr. de la Gandara, chief of psychiatry of the Hospital Complex of Burgos, Spain.

A single antidepressant is still the initial choice for treatment for most patients. Depending on the clinical picture, an anxiolytic or hypnotic may also be indicated. However, for some cases, it may be best to begin treatment with the combination of escitalopram plus mirtazapine. Possible indications for this initial combination would include severe depression, a history of poor antidepressant response, or clear risk of suicide.

All patients who fail to respond to a single antidepressant should be considered for combination therapy, according to the algorithm. It recommends the following antidepressant combinations:

* A selective serotonin reuptake inhibitor plus mirtazapine.

* Venlafaxine and mirtazapine (Remeron).

* An SSRI plus reboxetine.

* Mirtazapine plus a tricyclic.

* An SSRI plus a tricyclic.

* Mirtazapine plus moclobemide.

Anxiolytics or hypnotics should be maintained or discontinued according to the clinical picture. "In very severe cases, or with persistent suicidal ideation, consider a direct switch to electroconvulsive therapy," Dr. de la Gandara wrote.

The third treatment phase calls for continuing combination therapy with different drugs, and adding other drugs or going to electroconvulsive therapy. "Replace one or both antidepressants with totally different drugs with different mech anisms, or convert to 'second-level' combina tions [a tricyclic plus either mianserin or a monoamine oxidase inhibitor]."

BY MICHELE G. SULLIVAN Mid-Atlantic Bureau